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Beyond skin deep: addressing comorbidities in psoriasis

Tom Kovitwanichkanont, Alvin H Chong and Peter Foley
Med J Aust 2020; 212 (11): . || doi: 10.5694/mja2.50591
Published online: 11 May 2020

Summary

  • Psoriasis is a chronic inflammatory disease that is commonly encountered in primary care and is associated with significant morbidity that extends beyond the skin manifestations.
  • Psoriasis is associated with an elevated risk of psoriatic arthritis, cardiovascular disease, obesity, insulin resistance, mental health disorders, certain types of malignancy, inflammatory bowel disease and other immune‐related disorders, and hepatic and renal disease.
  • Enhanced recognition of these comorbidities may lead to earlier diagnosis and potentially better overall health outcomes.
  • Psoriatic nail involvement, severe skin disease and obesity are associated with a greater risk of psoriatic arthritis. Individuals with psoriasis should be routinely screened for psoriatic arthritis to allow for early intervention to improve long term prognosis.
  • Life expectancy is reduced in people with psoriasis due to a variety of causes, with cardiovascular disease and malignancy being the most common aetiologies.
  • Psoriasis affects several factors that contribute to worsened quality of life and increased risk of depression and anxiety. Effective therapies are now available that have been shown to concurrently improve skin disease, quality of life and psychiatric symptoms.
  • As the concordance between psychosocial impact and objective disease severity does not always correlate, it is essential to tailor management strategies specifically to the needs of each individual.
  • Cigarette smoking and excess alcohol consumption are among the most important modifiable risk factors that increase the likelihood of psoriasis development and severity of skin disease. This provides a compelling rationale for smoking cessation and limiting alcohol intake in people with psoriasis beyond their traditional harmful health consequences.

  • 1 Skin Health Institute, Melbourne, VIC
  • 2 St Vincent's Hospital, Melbourne, VIC



Competing interests:

Peter Foley is a consultant, investigator, speaker and/or advisor for, and/or received travel grants from 3M/iNova/Valeant, Abbott/AbbVie, Amgen, Biogen, Bristol Myers Squibb, Boehringer Ingelheim, Celgene, Celtaxsys, Cutanea, Dermira, Eli Lilly, Galderma, GSK/Stiefel, Janssen, LEO Pharma/Peplin, Novartis, Regeneron Pharmaceuticals, Roche, Sanofi Genzyme, Schering‐Plough/MSD, Sun Pharma, UCB and Wyeth/Pfizer.

  • 1. Parisi R, Symmons DP, Griffiths CE, Ashcroft DM. Global epidemiology of psoriasis: a systematic review of incidence and prevalence. J Invest Dermatol 2013; 133: 377–385.
  • 2. Ogdie A, Weiss P. The epidemiology of psoriatic arthritis. Rheum Dis Clin North Am 2015; 41: 545–568.
  • 3. Iragorri N, Hazlewood G, Manns B, et al. Psoriatic arthritis screening: a systematic review and meta‐analysis. Rheumatology (Oxford) 2019; 58: 692–707.
  • 4. Armstrong EJ, Harskamp CT, Armstrong AW. Psoriasis and major adverse cardiovascular events: a systematic review and meta‐analysis of observational studies. J Am Heart Assoc 2013; 2: e000062.
  • 5. Armstrong AW, Harskamp CT, Armstrong EJ. The association between psoriasis and obesity: a systematic review and meta‐analysis of observational studies. Nutr Diabetes 2012; 2: e54.
  • 6. Mamizadeh M, Tardeh Z, Azami M. The association between psoriasis and diabetes mellitus: a systematic review and meta‐analysis. Diabetes Metab Syndr 2019; 13: 1405–1412.
  • 7. Armstrong AW, Harskamp CT, Dhillon JS, Armstrong EJ. Psoriasis and smoking: a systematic review and meta‐analysis. Br J Dermatol 2014; 170: 304–314.
  • 8. Zhu KJ, Zhu CY, Fan YM. Alcohol consumption and psoriatic risk: a meta‐analysis of case‐control studies. J Dermatol 2012; 39: 770–773.
  • 9. Dowlatshahi EA, Wakkee M, Arends LR, Nijsten T. The prevalence and odds of depressive symptoms and clinical depression in psoriasis patients: a systematic review and meta‐analysis. J Invest Dermatol 2014; 134: 1542–1551.
  • 10. Dalgard FJ, Gieler U, Tomas‐Aragones L, et al. The psychological burden of skin diseases: a cross‐sectional multicenter study among dermatological out‐patients in 13 European countries. J Invest Dermatol 2015; 135: 984–991.
  • 11. Chi CC, Chen TH, Wang SH, Tung TH. Risk of suicidality in people with psoriasis: a systematic review and meta‐analysis of cohort studies. Am J Clin Dermatol 2017; 18: 621–627.
  • 12. Singh S, Taylor C, Kornmehl H, Armstrong AW. Psoriasis and suicidality: a systematic review and meta‐analysis. J Am Acad Dermatol 2017; 77(425–440): e2.
  • 13. Chen YJ, Chen CC, Lin MW, et al. Increased risk of sexual dysfunction in male patients with psoriasis: a nationwide population‐based follow‐up study. J Sex Med 2013; 10: 1212–1218.
  • 14. Wu T, Duan X, Chen S, et al. Association between psoriasis and erectile dysfunction: a meta‐analysis. J Sex Med 2018; 15: 839–847.
  • 15. Puig L, Thom H, Mollon P, et al. Clear or almost clear skin improves the quality of life in patients with moderate‐to‐severe psoriasis: a systematic review and meta‐analysis. J Eur Acad Dermatol Venereol 2017; 31: 213–220.
  • 16. Strober B, Gooderham M, de Jong E, et al. Depressive symptoms, depression, and the effect of biologic therapy among patients in Psoriasis Longitudinal Assessment and Registry (PSOLAR). J Am Acad Dermatol 2018; 78: 70–80.
  • 17. Pouplard C, Brenaut E, Horreau C, et al. Risk of cancer in psoriasis: a systematic review and meta‐analysis of epidemiological studies. J Eur Acad Dermatol Venereol 2013; 27(Suppl): 36–46.
  • 18. Gelfand JM, Shin DB, Neimann AL, et al. The risk of lymphoma in patients with psoriasis. J Invest Dermatol 2006; 126: 2194–2201.
  • 19. Fu Y, Lee CH, Chi CC. Association of psoriasis with inflammatory bowel disease: a systematic review and meta‐analysis. JAMA Dermatol 2018; 154: 1417–1423.
  • 20. Wu JJ, Nguyen TU, Poon KY, Herrinton LJ. The association of psoriasis with autoimmune diseases. J Am Acad Dermatol 2012; 67: 924–930.
  • 21. Chi CC, Tung TH, Wang J, et al. Risk of uveitis among people with psoriasis: a nationwide cohort study. JAMA Ophthalmol 2017; 135: 415–422.
  • 22. Candia R, Ruiz A, Torres‐Robles R, et al. Risk of non‐alcoholic fatty liver disease in patients with psoriasis: a systematic review and meta‐analysis. J Eur Acad Dermatol Venereol 2015; 29: 656–662.
  • 23. Ungprasert P, Raksasuk S. Psoriasis and risk of incident chronic kidney disease and end‐stage renal disease: a systematic review and meta‐analysis. Int Urol Nephrol 2018; 50: 1277–1283.
  • 24. Ritchlin CT, Colbert RA, Gladman DD. Psoriatic arthritis. N Engl J Med 2017; 376: 957–970.
  • 25. Wilson FC, Icen M, Crowson CS, et al. Incidence and clinical predictors of psoriatic arthritis in patients with psoriasis: a population‐based study. Arthritis Rheum 2009; 61: 233–239.
  • 26. Ogdie A, Langan S, Love T, et al. Prevalence and treatment patterns of psoriatic arthritis in the UK. Rheumatology (Oxford) 2013; 52: 568–575.
  • 27. Kehl AS, Corr M, Weisman MH. Review: enthesitis: new insights into pathogenesis, diagnostic modalities, and treatment. Arthritis Rheumatol 2016; 68: 312–322.
  • 28. Setty AR, Choi HK. Psoriatic arthritis epidemiology. Curr Rheumatol Rep 2007; 9: 449–454.
  • 29. Højgaard P, Ballegaard C, Cordtz R, et al. Gender differences in biologic treatment outcomes — a study of 1750 patients with psoriatic arthritis using Danish health care registers. Rheumatology (Oxford) 2018; 57: 1651–1660.
  • 30. Coates LC, Moverley AR, McParland L, et al. Effect of tight control of inflammation in early psoriatic arthritis (TICOPA): a UK multicentre, open‐label, randomised controlled trial. Lancet 2015; 386: 2489–2498.
  • 31. Haroon M, Gallagher P, FitzGerald O. Diagnostic delay of more than 6 months contributes to poor radiographic and functional outcome in psoriatic arthritis. Ann Rheum Dis 2015; 74: 1045–1050.
  • 32. Coates LC, Aslam T, Al Balushi F, et al. Comparison of three screening tools to detect psoriatic arthritis in patients with psoriasis (CONTEST study). Br J Dermatol 2013; 168: 802–807.
  • 33. Menter A, Strober BE, Kaplan DH, et al. Joint AAD‐NPF guidelines of care for the management and treatment of psoriasis with biologics. J Am Acad Dermatol 2019; 80: 1029–1072.
  • 34. Langenbruch A, Radtke MA, Krensel M, et al. Nail involvement as a predictor of concomitant psoriatic arthritis in patients with psoriasis. Br J Dermatol 2014; 171: 1123–1128.
  • 35. Reich K. The concept of psoriasis as a systemic inflammation: implications for disease management. J Eur Acad Dermatol Venereol 2012; 26 (Suppl): 3–11.
  • 36. Skiveren J, Philipsen P, Therming G. Patients with psoriasis have insufficient knowledge of their risk of atherothrombotic disease and metabolic syndrome. Clin Exp Dermatol 2015; 40: 600–604.
  • 37. Navarini L, Margiotta DPE, Caso F, et al. Performances of five risk algorithms in predicting cardiovascular events in patients with psoriatic arthritis: an Italian bicentric study. PLoS One 2018; 13: e0205506.
  • 38. Roubille C, Richer V, Starnino T, et al. The effects of tumour necrosis factor inhibitors, methotrexate, non‐steroidal anti‐inflammatory drugs and corticosteroids on cardiovascular events in rheumatoid arthritis, psoriasis and psoriatic arthritis: a systematic review and meta‐analysis. Ann Rheum Dis 2015; 74: 480–489.
  • 39. Ahlehoff O, Skov L, Gislason G, et al. Cardiovascular outcomes and systemic anti‐inflammatory drugs in patients with severe psoriasis: 5‐year follow‐up of a Danish nationwide cohort. J Eur Acad Dermatol Venereol 2015; 29: 1128–1134.
  • 40. Ridker PM, Everett BM, Pradhan A, et al. Low‐dose methotrexate for the prevention of atherosclerotic events. N Engl J Med 2019; 380: 752–762.
  • 41. Bissonnette R, Harel F, Krueger JG, et al. TNF‐alpha antagonist and vascular inflammation in patients with psoriasis vulgaris: a randomized placebo‐controlled study. J Invest Dermatol 2017; 137: 1638–1645.
  • 42. Chung ES, Packer M, Lo KH, et al. Randomized, double‐blind, placebo‐controlled, pilot trial of infliximab, a chimeric monoclonal antibody to tumor necrosis factor‐alpha, in patients with moderate‐to‐severe heart failure: results of the anti‐TNF Therapy Against Congestive Heart Failure (ATTACH) trial. Circulation 2003; 107: 3133–3140.
  • 43. Egeberg A, Sørensen JA, Gislason GH, et al. Incidence and prognosis of psoriasis and psoriatic arthritis in patients undergoing bariatric surgery. JAMA Surg 2017; 152: 344–349.
  • 44. Jensen P, Zachariae C, Christensen R, et al. Effect of weight loss on the severity of psoriasis: a randomized clinical study. JAMA Dermatol 2013; 149: 795–801.
  • 45. Wan MT, Shin DB, Hubbard RA, et al. Psoriasis and the risk of diabetes: a prospective population‐based cohort study. J Am Acad Dermatol 2018; 78(315–322): e1.
  • 46. Michaёlsson G, Gustafsson K, Hagforsen E. The psoriasis variant palmoplantar pustulosis can be improved after cessation of smoking. J Am Acad Dermatol 2006; 54: 737–738.
  • 47. Nguyen UDT, Zhang Y, Lu N, Louie‐Gao Q, et al. Smoking paradox in the development of psoriatic arthritis among patients with psoriasis: a population‐based study. Ann Rheum Dis 2018; 77: 119–123.
  • 48. Naldi L, Chatenoud L, Linder D, et al. Cigarette smoking, body mass index, and stressful life events as risk factors for psoriasis: results from an Italian case‐control study. J Invest Dermatol 2005; 125: 61–67.
  • 49. Ko SH, Chi CC, Yeh ML, et al. Lifestyle changes for treating psoriasis. Cochrane Database Syst Rev 2019; (7): CD011972.
  • 50. Kurd SK, Troxel AB, Crits‐Christoph P, Gelfand JM. The risk of depression, anxiety, and suicidality in patients with psoriasis: a population‐based cohort study. Arch Dermatol 2010; 146: 891–895.
  • 51. Kimball AB, Jacobson C, Weiss S, et al. The psychosocial burden of psoriasis. Am J Clin Dermatol 2005; 6: 383–392.
  • 52. Aberra TM, Joshi AA, Lerman JB, et al. Self‐reported depression in psoriasis is associated with subclinical vascular diseases. Atherosclerosis 2016; 251: 219–225.
  • 53. Dauden E, Griffiths CE, Ortonne JP, et al. Improvements in patient‐reported outcomes in moderate‐to‐severe psoriasis patients receiving continuous or paused etanercept treatment over 54 weeks: the CRYSTEL study. J Eur Acad Dermatol Venereol 2009; 23: 1374–1382.
  • 54. Hawro M, Maurer M, Weller K, et al. Lesions on the back of hands and female gender predispose to stigmatization in patients with psoriasis. J Am Acad Dermatol 2017; 76(648–654): e2.
  • 55. Sampogna F, Tabolli S, Abeni D. Living with psoriasis: prevalence of shame, anger, worry, and problems in daily activities and social life. Acta Derm Venereol 2012; 92: 299–303.
  • 56. Armstrong AW, Schupp C, Wu J, Bebo B. Quality of life and work productivity impairment among psoriasis patients: findings from the National Psoriasis Foundation survey data 2003–2011. PLoS One 2012; 7: e52935.
  • 57. Molina‐Leyva A, Jiménez‐Moleón JJ, Naranjo‐Sintes R, Ruiz‐Carrascosa JC. Sexual dysfunction in psoriasis: a systematic review. J Eur Acad Dermatol Venereol 2015; 29: 649–655.
  • 58. Matterne U, Baumeister SE, Apfelbacher CJ. Suicidality and risk of suicidality in psoriasis: a critical appraisal of two systematic reviews and meta‐analyses. Br J Dermatol 2019; 181: 717–721.
  • 59. Chiesa Fuxench ZC, Shin DB, Ogdie Beatty A, Gelfand JM. The risk of cancer in patients with psoriasis: a population‐based cohort study in the Health Improvement Network. JAMA Dermatol 2016; 152: 282–290.
  • 60. Crusz SM, Balkwill FR. Inflammation and cancer: advances and new agents. Nat Rev Clin Oncol 2015; 12: 584–596.
  • 61. Peleva E, Exton LS, Kelley K, et al. Risk of cancer in patients with psoriasis on biological therapies: a systematic review. Br J Dermatol 2018; 178: 103–113.
  • 62. Sokolova A, Lee A, Saxon DS. The safety and efficacy of narrow band ultraviolet B treatment in dermatology: a review. Am J Clin Dermatol 2015; 16: 501–531.
  • 63. Papp KA, Griffiths CE, Gordon K, et al. Long‐term safety of ustekinumab in patients with moderate‐to‐severe psoriasis: final results from 5 years of follow‐up. Br J Dermatol 2013; 168: 844–854.
  • 64. Fiorentino D, Ho V, Lebwohl MG, et al. Risk of malignancy with systemic psoriasis treatment in the Psoriasis Longitudinal Assessment Registry. J Am Acad Dermatol 2017; 77(845–854): e5.
  • 65. Papp K, Gottlieb AB, Naldi L, et al. Safety surveillance for ustekinumab and other psoriasis treatments from the Psoriasis Longitudinal Assessment and Registry (PSOLAR). J Drugs Dermatol 2015; 14: 706–714.
  • 66. Gottlieb AB, Kalb RE, Langley RG, et al. Safety observations in 12095 patients with psoriasis enrolled in an international registry (PSOLAR): experience with infliximab and other systemic and biologic therapies. J Drugs Dermatol 2014; 13: 1441–1448.
  • 67. Rademaker M, Rubel DM, Agnew K, et al. Psoriasis and cancer. an Australian/New Zealand narrative. Australas J Dermatol 2019; 60: 12–18.
  • 68. Ayala‐Fontánez N, Soler DC, McCormick TS. Current knowledge on psoriasis and autoimmune diseases. Psoriasis (Auckl) 2016; 6: 7–32.
  • 69. Alinaghi F, Tekin HG, Burisch J, et al. Global prevalence and bidirectional association between psoriasis and inflammatory bowel disease — a systematic review and meta‐analysis. J Crohns Colitis 2019; 14: 351–360.
  • 70. Egeberg A, Thyssen JP, Burisch J, Colombel JF. Incidence and risk of inflammatory bowel disease in patients with psoriasis — a nationwide 20‐year cohort study. J Invest Dermatol 2019; 139: 316–323.
  • 71. Pugliese D, Guidi L, Ferraro PM, et al. Paradoxical psoriasis in a large cohort of patients with inflammatory bowel disease receiving treatment with anti‐TNF alpha: 5‐year follow‐up study. Aliment Pharmacol Ther 2015; 42: 880–888.
  • 72. Cottone M, Sapienza C, Macaluso FS, Cannizzaro M. Psoriasis and inflammatory bowel disease. Dig Dis 2019; 37: 451–457.
  • 73. Eppinga H, Poortinga S, Thio HB, et al. Prevalence and phenotype of concurrent psoriasis and inflammatory bowel disease. Inflamm Bowel Dis 2017; 23: 1783–1789.
  • 74. Chandran V, Cook RJ, Edwin J, et al. Soluble biomarkers differentiate patients with psoriatic arthritis from those with psoriasis without arthritis. Rheumatology (Oxford) 2010; 49: 1399–1405.
  • 75. Ogdie A, Grewal SK, Noe MH, et al. Risk of incident liver disease in patients with psoriasis, psoriatic arthritis, and rheumatoid arthritis: a population‐based study. J Invest Dermatol 2018; 138: 760–767.
  • 76. Shahwan KT, Kimball AB. Psoriasis and cardiovascular disease. Med Clin North Am 2015; 99: 1227–1242.
  • 77. Grewal SK, Wan J, Denburg MR, et al. The risk of IgA nephropathy and glomerular disease in patients with psoriasis: a population‐based cohort study. Br J Dermatol 2017; 176: 1366–1369.
  • 78. Warren RB, Weatherhead SC, Smith CH, et al. British Association of Dermatologists’ guidelines for the safe and effective prescribing of methotrexate for skin disease 2016. Br J Dermatol 2016; 175: 23–44.

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